Public use of tourniquets, bleeding control kits

Although large scale multiple casualty incidents such as the Boston Marathon bombing and the San Bernardino shooting capture the nation's attention smaller scale MCIs are much more common. The National Association of State EMS Officials provides one definition of an MCI as any incident "which generates more patients at one time than locally available resources can manage using routine procedures [1]. Using that definition, researchers estimate the yearly incident rate in the United States is about 13.0 MCIs per 100,000 population [2].

Hemorrhage is the second leading cause of death for patients injured in the prehospital environment, accounting for 30-40 percent of all mortality [3]. Many of the patients who hemorrhage do so after suffering vascular injuries in one or more extremities. The annual incidence of extremity vascular injuries in the United States ranges from a low of 12.4 injuries at a rural trauma center in Missouri [4] to a high of 55 lower extremity injuries at a high-volume urban trauma center in Houston [5]. In a study of isolated penetrating injuries to the extremities, 57 percent of the patients who died had injuries that might have been amenable to tourniquet application [6].

There is little debate about the value of rapid hemorrhage control for improving outcomes in critically injured trauma patients. The American College of Surgeons Committee on Trauma has stated that bleeding must be controlled by prehospital providers as quickly as possible.

For maximum efficiency, health care providers must apply tourniquets before the patient has developed shock [7]. During Operation Iraqi Freedom, tourniquets applied in the field and before the onset of shock were strongly associated with survival [8].

Unfortunately, in cases of severe bleeding, trained professionals may not always arrive in time to prevent exsanguination. Researchers in Austria and Germany found that when traumatic injury occurs, bystanders with varying levels of first aid training are often present on scene before EMS arrives [9].

In addition, these bystanders often attempt to provide hemorrhage control for patients suffering from an exsanguinating injury. Although prior first aid training increased the probability of successful hemorrhage control by the bystander, the lack of first aid training did not prevent bystanders from attempting to control bleeding and a significant percentage were successful.

Can the public help
A central question is whether these bystanders who are present on the scene and are willing to help control severe bleeding can become part of a trauma chain of survival. There is very little data in support of this position. However, studies involving a cardiac arrest chain of survival demonstrate that trained bystanders can safely and effectively use defibrillators to resuscitate victims of out-of-hospital cardiac arrest [10-14]. Even sixth graders with no previous medical training can achieve performance goals similar to those achieved by trained medical responders [15].

Similarly, is it reasonable to think ordinary citizens would be able to safely and effectively apply tourniquets when indicated before the arrival of EMS personnel. Limited available evidence suggests it is.

During a simulated explosion, one in five people with no medical training were able to correctly apply a commercially available tourniquet to a manikin's leg in less than 60 seconds [16]. Providing instructions on a notecard with the tourniquet more than doubled the rate of successful placements.

During the Boston Marathon bombing, 29 patients with life-threatening limb exsanguination had 27 improvised tourniquets applied in the field [17]. EMS personnel applied one-third of those tourniquets and non-EMS personnel or an unknown person applied the remainder.

In a 10-year evaluation of isolated penetrating or blunt extremity injury requiring either arterial revascularization or limb amputation at Boston Medical Center, only 2 percent of patients had a tourniquet applied before arriving at the trauma center and all were improvised tourniquets applied by police officers or bystanders [18]. An additional 2 percent of patients had a tourniquet applied by emergency department staff within one hour of arrival. While a very small number of patients without a tourniquet exsanguinated, no patient with a tourniquet died.

During a seven-year period, researchers at Boston Medical Center identified 11 patients who had an improvised tourniquet applied in the field by EMS [19]. Only one patient died, however, that patient was in cardiac arrest when EMS arrived on the scene. Of the 10 patients who survived, all had complete neurologic function in the affected extremity despite having the tourniquet in place for as long as 167 minutes (mean 75 +\- 38 minutes).

One concern about bystander application of a tourniquet is whether the bystander will be able to apply the device tightly enough to be effective. Indeed, a manikin study involving non-medical trained bystanders found that 70 percent of the incorrectly placed tourniquets were judged to be too loose [16]. However, a battlefield evaluation found that although morbidity remained high with partially ineffective tourniquet application (persistent distal pulses), mortality actually improved when compared to totally ineffective tourniquets (continued bleeding) [20]. This suggests that even when tourniquets are not tight enough to be totally effective, they may still be better than no tourniquet at all.

Hemorrhage-control training courses for the lay rescuer
The American College of Surgeons convened a special committee to identify changes necessary to improve survival following active shooter and MCIs [21]. One of the major themes to emerge from these series of meetings, known as the Hartford Consensus, is that the public will act as responders to provide aid before the arrival of professional rescuers.

Another major theme of the Hartford Consensus, which was the focus of the second Hartford Consensus Conference, is the value of a comprehensive educational program for all members of this trauma chain of survival. Critical to this concept and the focus of third Hartford Consensus Conference, is educational campaigns targeting members of the general public, which should include training on how to apply direct pressure, how to use hemostatic dressings, and how to apply tourniquets [22].

In response to the Hartford consensus, the EMS Education Department of the Denver Paramedic Division, in cooperation with the Prehospital Trauma Life Support committee of the National Association of EMTs developed training program targeting ordinary citizens [23]. The 2.5-hour Bleeding Control for the Injured course combines didactic lectures with hands-on training to teach the lay rescuer important life-saving skills such as hemorrhage control and how to open an airway [24].

Also in response to the Hartford Consensus, the White House launched the "Stop the Bleed" campaign [25]. This campaign hopes to provide public awareness to the simple steps that anyone can take to slow life-threatening bleeding. The campaign also promotes the placement of Bleeding Control Kits in public spaces that would allow members of the general public access to life-saving supplies, similar to public access defibrillation programs.

In 2015, the Harvard School of Public Education and the Harvard School of Government began a bleeding control pilot program at Charlotte Douglas International Airport [26]. The team placed bleeding control kits inside of each AED cabinet in the airport. Each kit contained pressure dressings, hemostatic dressings, tourniquets, and personal protective gloves. After training the airport emergency staff on the contents, use and location of the kits, the pilot team in conjunction with airport police, conducted three active shooter scenarios. After-action reporting indicated the responders were able to locate and appropriately use the kits in a simulated incident.

Bystander action is a result of competence from training
The military experience has demonstrated that complications associated with tourniquet use are rare, even when the tourniquet is improvised. The limited civilian data supports the safety of the tourniquets

Bystanders are often present on the scene of a traumatic injury before professional rescuers. In some cases, bystander care may mean the difference between whether the patient survives or not. Experience with CPR and AEDs has demonstrated that bystanders will attempt to intervene especially if they are trained and have easy access to the equipment.

Bystanders who self-report a feeling of competence to provide emergency first aid are more likely to help victims of traumatic injury [27]. That feeling of competence is positively correlated to first aid training. Those with first aid training feel competent to provide care before EMS arrives on the scene to take over [28].

With untrained bystanders as part of the definition of a first responder, the Office of Health Affairs at the Department of Homeland Security recommends the availability of both tourniquets and hemostatic agents in the early management of severe bleeding [7]. Lay rescuers play a vital role in providing immediate bleeding control while awaiting the arrival of traditional first responders [29].

References

1. National Association of State EMS Officials. (2012). Extended definition document NEMSIS/NHTSA 2.2.1 data dictionary. Retrieved from http://ift.tt/1WuVN6w.
2. Schenk, E., Wijetunge, G., Mann, N. C., Lerner, E. B., Longthorne, A., & Dawson, D. (2014). Epidemiology of mass casualty incidents in the United States. Prehospital Emergency Care, 18(3), 408–416. doi:10.3109/10903127.2014.882999
3. Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. The Journal of Trauma, Injury, Infection, and Critical Care, 60(6), S3-S11. doi:10.1097/01.ta.0000199961.02677.19
4. Humphrey, P. W., Nichols, W. K., & Silver, D. (1994). Rural vascular trauma: A twenty-year review. Annals of Vascular Surgery, 8(2), 179-185.
5. Feliciano, D. V., Herskowitz, K., O'Gorman, R. B., Cruse, P. A., Brandt, M. L., Burch, J. M., & Mattox, K. L. (1988). Management of vascular injuries in the lower extremities. Journal of Trauma, 28(3), 319-328.
6. Dorlac, W. C., DeBakey, M. E., Holcomb, J. B., Fagan, S. P., Kwong, K. L., Dorlac, G. R., Schreiber, M. A., Persse, D. E., Moore, F. A., & Mattox, K. L. (2005). Mortality from isolated civilian penetrating extremity injury. Journal of Trauma, 59(1), 217-222.
7. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from http://ift.tt/1TUxsDG
8. Kragh, J. F. Jr., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7. doi:10.1097/SLA.0b013e31818842ba
9. Pelinka, L. E., Thierbach, A. R., Reuter, S., & Mauritz, W. (2004). Bystander trauma care – effect of the level of training. Resuscitation, 61(3), 289-296. doi:10.1016/j.resuscitation.2004.01.012
10. MacDonald, R. D., Mottley, J. L., & Weinstein, C. (2002). Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehospital Emergency Care, 6(1), 1-5. doi:10.1080/10903120290938689
11. O'Rourke, M. F., Donaldson, E. E., & Geddes, J. S. (1997). An airline cardiac arrest program. Circulation, 96(9), 2849-2853. doi:10.1161/01.CIR.96.9.2849
12. Page, R. L., Joglar, J. A., Kowal, R. C., Zagrodzky, J. D., Nelson, L. L., Ramaswamy, K., Barbera, S. J., Hamdan, M. H., & McKenas, D. K. (2000). Use of automated external defibrillators by a U.S. airline. New England Journal of Medicine, 343(17), 1210-1216. doi:10.1056/NEJM200010263431702
13. Valenzuela, T. D., Roe, D. J., Nichol, G., Clark, L. L., Spaite, D. W., & Hardman, R. G. (2000). Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine, 343(17), 1206-1209. doi:10.1056/NEJM200010263431701
14. Wassertheil, J., Keane, G., Fisher, N., & Leditschke, J. F. (2000). Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy — a forerunner to public access defibrillation. Resuscitation, 44(2), 97-104. doi:10.1016/S0300-9572(99)00168-9
15. Gundry, J. W., Comess, K. A., DeRook, F. A., Jorgenson, D., & Bardy, G. H. (1999). Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation, 100(16), 1703-1707. doi:10.1161/01.CIR.100.16.1703
16. Goolsby, C., Branting, A., Chen, E., Mack, E., & Olsen, C. (2015). Just-in-time to save lives: A pilot study of layperson tourniquet application. Academic Emergency Medicine, 22(9), 1113-1117. doi:10.1111/acem.12742
17. King, D. R., Larentzakis, A., & Ramly, E. P. (2015). Tourniquet use at the Boston Marathon bombing: Lost in translation. Journal of Trauma and Acute Care Surgery, 78(3), 594-599. doi:10.1097/TA.0000000000000561
18. Kalish, J., Burke, P., Feldman, J., Agarwal, S., Glantz, A., Moyer, P., Serino, R., & Hirsch, E. (2008). The return of tourniquets. Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. Journal of the Emergency Medical Services, 33(8), 44–54. doi:10.1016/S0197-2510(08)70289-4
19. Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962
20. Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma Injury, Infection, and Critical Care, 64(Suppl 2), S38–S49. doi:10.1097/TA.0b013e31816086b1
21. Jacobs, L. M., Wade, D., McSwain, N. E., Butler, F. K., Fabbri, W., Eastman, A., Conn, A., & Burns, K. J.. (2014). Hartford consensus: A call to action for THREAT, a medical disaster preparedness concept. Journal of the American College of Surgeons, 218(3), 467–475. doi:10.1016/j.jamcollsurg.2013.12.009
22. Jacobs, L. M. Jr., & the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. (2016). The Hartford consensus IV: A call for increased national resilience. Bulletin of the American College of Surgeons, 101(3), 17-24.
23. Pons, P. T., Jerome, J., McMullen, J., Manson, J., Robinson, J., & Chapleau, W. (2015). The Hartford consensus on active shooters: Implementing the continuum of prehospital trauma response. The Journal of Emergency Medicine, 49(6), 878–885. doi:10.1016/j.jemermed.2015.09.013
24. National Association of EMTs. (2016). Bleeding control for the injured. Retrieved from http://ift.tt/1WuWgWp
25. The White House, Office of the Press Secretary. (2015). Fact Sheet: Bystander: "Stop the Bleed" broad private sector support for effort to save lives and build resilience. Retrieved from http://ift.tt/1TUx3kI
26. National Preparedness Leadership Initiative. (2015). Public access bleeding control: An implementation strategy. Retrieved from http://ift.tt/1WuVUyS
27. Thierbach, A. R., Pelinka, L. E., Reuter, S., & Mauritz, W. (2004). Comparison of bystander trauma care for moderate versus severe injury. Resuscitation, 60(3), 271-277. doi:10.1016/j.resuscitation.2003.11.008
28. Steele, J. A. (1994). The effects of first aid training on public awareness of the management of a seriously injured patient. Journal of the Royal Society of Health, 114(2), 67–68. doi:10.1177/146642409411400204
29. Jacobs, L. M. Jr., & the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. (2015). The Hartford consensus III: Implementation of bleeding control – if you see something, do something. Bulletin of the American College of Surgeons, 100(7), 20-26.

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